Boring Question: How useful are physical examination manoeuvres for an adult patient with suspected meningitis?

In Clinical Questions by Jatin Kaicker4 Comments

Background

For a patient who presents with a headache, it is imperative to consider a broad initial differential diagnosis to rule out life threatening causes such as meningitis. Bacterial meningitis is a medical emergency with an annual incidence of 4 to 6 cases per 100,000 adults, with early treatment considerations being essential (1). We are commonly taught to consider a triad of symptoms including fever, neck stiffness and altered mental status. However, the sensitivity of this triad is about 44% (1). For adult patients with bacterial meningitis, the most common infectious agents are Streptococcus pneumoniae and Neisseria meningitides, which are responsible for 80 percent of all cases (1).

The Case

A 30-year-old male comes to the emergency department with a bilateral headache that started on his right side and has increased in intensity over the past three days. He describes the headache as pulsatile in nature. He denies any vomiting but feels nauseous and requests that the lights are turned off. He has not noticed any new rashes on his body or neck stiffness. He does not wear glasses and visits his optometrist every two years. He lives in an apartment with three close friends, none of whom have been ill in the last few weeks. He denies any focal neurological deficits. He has not had any trauma to the head or neck. His friends deny any recent changes in his personality or confusion. He is otherwise healthy with no other medical conditions. He is particularly concerned about having meningitis, having witnessed the disease in his sibling two years ago. He mentioned that his mother suffers from migraines.

Vitals: His temperature was 37.5 degrees Celsius with a heart rate of 98, respiratory rate of 18, blood pressure of 130/80 and oxygen saturation of 98 percent on room air.

On physical examination, he was alert and oriented to person, place and time. His neurological examination was unremarkable. Neck was supple. Jolt accentuation, Kernig and Brudzinski signs were not appreciated in the patient. Dermatological assessment did not reveal any rashes on his body.

The Clinical Question

How useful are physical examination manoeuvres for a patient with suspected meningitis?

Review of Examination Manoeuvres for Meningitis

Kernig Sign

With a patient in the supine position, passively flex hip to 90 degrees while the knee is also flexed at about 90 degrees. With the hips in flexion, an attempt to extend the knee produces pain in the hamstrings and resistance to further extension. This is a sign of meningeal irritation (2, 5).

 Brudzinski Sign

With the patient supine and limbs extended, passively flex neck. Flexion of the hips is considered a positive Brudzinski sign, a sign of meningeal irritation (2, 5).

Jolt Accentuation

The patient turns their head horizontally at frequency of 2 to 3 rotations per second. Worsening of the baseline headache may suggest meningitis (2, 5).

Nuchal Rigidity

The patient is unable to flex neck to place chin on chest (2).

The Search Strategy

Using PubMed, three separate searches were performed. These were:

  1. ‘Brudzinski sign’ AND Meningitis
  2. ‘Kernig sign’ AND Meningitis
  3. ‘Jolt Accentuation’ AND Meningitis

The resulting abstracts were screened with relevant articles reviewed. In addition to the literature, the textbook ‘Tintinalli’s Emergency Medicine’ and NEJM overview of meningitis were used.

The Evidence

  • In 1999, Attia et al published a piece in JAMA’s Rational Clinical Examination Series using the available literature to date around adult patients with meningitis. They found that jolt accentuation was the most useful manoeuvre with a positive likelihood ratio of 2.2 (sensitivity 100%, specificity 54%) (3).
  • A prospective cross-sectional investigation in 2002 involved 297 adults with suspected meningitis. It found that both the Kernig and Brudzinski signs both had a positive likelihood ratio of 0.97 (5% sensitivity, 95% specificity)(4). For nuchal rigidity, the positive likelihood ratio was 0.94 (sensitivity 30%, specificity 68%).
  • An investigation by Waghdhare et al in 2010 assessed 190 patients and found that none of the physical signs used to assess meningeal inflammation are accurate enough to allow clinicians to confidently rule in or out meningitis in adult inpatients. From their findings, jolt accentuation had the highest positive likelihood ratio at 5.52 (sensitivity 6%, specificity 98.9%). For the Kernig sign it was 1.84 (sensitivity 14%, specificity 92%) and 1.69 for the Brudzinski’s sign (sensitivity 11%, specificity 93%) (5). Finally for nuchal rigidity, the positive likelihood ratio was 1.33 (sensitivity 39.4%, specificity 70.3%).
  • Tamune et al in 2013 assessed 531 patients in which meningitis was diagnosed in 139 individuals after lumbar puncture. This investigation specifically assessed jolt accentuation and found a positive likelihood ratio of 1.12 (sensitivity 64%, specificity 43%) (6).
  • Finally, Nakao et al in 2014 conducted an observational study of 230 neurologically intact adults patients in the emergency department undergoing a lumbar puncture in New York City. They found that in predicting pleocytosis, the positive likelihood ratio for Jolt Accentuation was 1.2 (sensitivity 21%, specificity 82%) while being 0.8 (sensitivity 2%, specificity 97%) and 1.0 (sensitivity 2%, specificity 98%) for the Kernig and Brudzinski signs respectively (7). For nuchal rigidity, the positive likelihood ratio was 0.6 (sensitivity 13%, specificity 80%).

Summary Chart of Test Characteristics

Physical SignSensitivitySpecificityLikelihood Ratio (+)
Jolt Accentuation100% (3)
6% (5)
64% (6)
21% (7)
54%(3)
98.9% (5)
43% (6)
82% (7)
2.2(3)
5.5(5)
1.1 (6)
1.2 (7)
Kernig5% (4)
14% (5)
2% (7)
95% (4)
92% (5)
97% (7)
0.97(4)
1.84(5)
0.8 (7)
Brudinzki5%(4)
11% (5)
2% (7)
95%(4)
93% (5)
98% (7)
0.97(4)
1.69 (5)
1.0 (7)
Nuchal Rigidity30% (4)
39.4% (5)
13% (7)
68% (4)
70.3% (5)
80% (7)
0.95 (4)
1.33 (5)
0.6 (7)


The Bottom Line

The Kernig, Brudzinski and Jolt Accentuation signs have limited utility in assessing patients with acute meningitis. The poor sensitivities mean that meningitis cannot be ruled out if the signs are not present (remember sn[out]). The relatively high specificities mean that your suspicion might increase if the signs are present (remember sp[in]) but unfortunately the associated low positive likelihood ratios show that no exam manoeuvre can reliably rule in the diagnosis. All three must be used with caution and in conjunction with other supporting laboratory and historical data.

 References

  1. Van de Beek D, de Gans J, Tunkel AR, Wijdicks EFM. (2006) Community Acquired Bacterial Meningitis in Adults. New England Journal of Medicine 354:44:53. PMID: 16394301
  1. Tintinalli’s Emergency Medicine-A Comprehensive Study Guide. (2011). New York. McGraw Hill Companies Inc.
  1. Attia J, Hatala R, Cook DJ, Wong JG. (1999) Does this adult patient have acute meningitis? JAMA 281: 175-181.PMID: 10411200. 
  2. Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. (2002)The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. Clin Infect Dis 35:46–52. PMID: 12060874
  1. Waghdhare S, Kalantri A, Joshi R, Kalantri S. (2010) Accuracy of physical signs for detecting meningitis: A hospital-based diagnostic accuracy study. Clinical Neurology and Neurosurgery 112: 752-757. PMID: 20615607
  1. Tamune H, Takeya H, Suzuki W, Tagashira Y, Kuki T, Nakamura M. (2013). Absence of jolt accentuation of headache cannot accurately rule out meningitis in adults. American Journal of Emergency Medicine 31: 1601-1604. PMID: 24070978
  1. Nakao JH, Jafri FN, Shah K, Newman DH. (2014). Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. American Journal of Emergency Medicine 32: 24-28.PMID: 24139448

Reviewing with Staff (Dr. Joanna Bostwick)

There are a few take home clinical points from Jatin’s extensive review.

1- Clinical signs and symptoms have very low yield in ruling in a diagnosis of meningitis. As highlighted in this piece, the physical exam manoeuvres such as the jolt accentuation, Kernig sign and Brudzinski sign may be present in a patient with meningitis but do not exclude the diagnosis if not seen. The jolt accentuation may be the most useful of the three manoeuvres; however actually performing such a test on a patient with a headache is more like torture than good medicine!

2-Given the gravity of the illness, if you suspect meningitis, a lumbar puncture should be performed to confirm the diagnosis (in the absence of any contraindications).

3-Never delay antibiotics. Start with ceftriaxone 2g IV empirically

Reviewed by Eve Purdy & Dr. Joanna Bostwick.

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BoringEM has been 'bringing the boring' to emergency medicine since 2012. In 2016 this Canadian blog brought its content to CanadiEM.
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